Prostate calcifications are also frequently seen among these patients on prostate transrectal ultrasonography [11]. Patients with the inflammatory subtype of chronic prostatitis NIH category III have leukocytes in the expressed prostatic secretions, urine after prostate massage, and/or semen fluid. Leukocytes in human semen are usually counted after a histochemical procedure that identifies the peroxidase enzyme and the subsequent presence of ≥1 × 10⁶ WBC/ml (WHO 2010 definition) [12, 13]. Some authors consider this value too high, whereas others consider the counts below the WHO threshold to be associated with deterioration of semen quality [6]. Most leukocytes are neutrophils highly reactive to the peroxidase reaction [12]. Leukocytospermia may be associated with bacterial infection [12]. This is the reason why all these cases should be adequately investigated with microbiological investigations although the Meares test as gold standard method for diagnosis is not so popular among urologists. Conversely patients without evidence of inflammation in the seminal fluid are always classified as noninflammatory subtype category III prostatitis.

Patients with no clinical signs or symptoms of prostatitis (pain and/or urinary and/or sexual complaints) but the presence of leukocytes in the semen are commonly classified in the asymptomatic inflammatory prostatitis group (NIH classification category IV). Many of these patients are diagnosed during clinical evaluations for other genitourinary tract issues such as infertility and diagnostic work-up in patients with suspicion of prostate cancer due to raised prostate-specific antigen levels. Inflammatory asymptomatic prostatitis has also been found in the control group of subjects enrolled in observational studies on prostatitis and other prostate diseases. Positive microbiological semen analyses were also found in a limited number of these subjects [6, 14].

In conclusion, the prostatitis NIH classification seems to be able to objectively characterize patients according to specific criteria, but it is suboptimal to determine the effects of different types of treatment on patient symptoms. Evaluation of seminal fluid content is often difficult because leukocytes are frequently indistinguishable from immature sperms and some of them can also be easily collected from urethral secretions during the ejaculation process. Therefore, it is mandatory to collect the seminal fluid just after the first voided urine prior to ejaculation to obtain reliable results. The histochemical peroxidase enzyme determination is a reliable discriminating factor in the diagnosis of inflammatory disease. Antimicrobials are effective in the treatment of acute prostatitis and chronic bacterial prostatitis. In all these cases besides the clinical improvement of subjective symptoms, repeated microbiological semen analyses are mandatory to demonstrate the complete and permanent eradication of infection. In patients with inflammatory chronic abacterial prostatitis, some infective microorganisms such as Chlamydia trachomatis and Ureaplasma urealyticum can be easily found in the semen, but their role in the pathogenesis of the disease is still largely debated. Most investigators state that these are not causative agents in abacterial prostatitis. On the other hand, Ureaplasma urealyticum and Chlamydia trachomatis have been found in about 10 % and 30 %, respectively, of subjects previously diagnosed with abacterial prostatitis by different authors. Some of these patients indeed respond successfully to the treatment with tetracycline or macrolides. In any case, all patients with chronic abacterial prostatitis, which remains the more frequent type of the disease, are difficult to diagnose, treat, and monitor. We need more accurate investigational criteria preferably based on specific symptoms.